Malignant melanoma

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Malignant melanoma

J A S C A P

JEET ASSOCIATION FOR SUPPORT TO CANCER PATIENTS MUMBAI INDIA

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JASCAP JEET ASSOCIATION FOR SUPPORT TO CANCER PATIENTS

co Abhay Bhagat amp Co Office No4 ldquoShilpardquo 7thRoad Prabhat Colony Santacruz (East) Mumbai ndash 400 055

Tel 2617 7543 2616 0007 Fax 91-22-2618 6162 E-mail pkrjascapgmailcom amp abhayabhaybhagatcom

JASCAP is a charitable trust that provides information on various aspects of cancer This can help the patient and his family to understand the disease and its treatment and thus cope with it better Registered under the Societies Registration Act 1860 No1359 1996 GBBSD Mumbai and under the Bombay Public Trusts Act 1950 No 18751 (Mumbai) Donations to JASCAP qualify for deduction us 80G (1) of the Income Tax Act 1961 vide Certificate No DIT (E) BC 80G 1383 96-97 dated 280297 subsequently renewed

Contact Mr Prabhakar K Rao or Mrs Neera P Rao Publisher JASCAP Mumbai 400 055 Printer Surekha Press Mumbai 400 019 Edition March 2011

o copy Cancerbackup March 2009 o This booklet is an adaptation of ldquounderstanding malignant melanomardquo

produced by Cancerbackup and is reproduced with their kind permission

o JASCAP gratefully acknowledges Cancerbackuprsquos permission to reproduce this booklet

Donation suggested Rs2500

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Contents General

What is melanoma What is cancer Types of cancer The skin Types of melanoma

Causes amp diagnosis

Causes Symptoms Diagnosis Staging

Treatment

Thin melanoma Stage 2 amp 3 melanoma Advanced melanoma

After treatment

Follow up After melanoma

Clinical trials

Research - clinical trials

Resources amp support

Living with cancer

JASCAP Resources

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Malignant Melanoma

What is malignant melanoma

Melanoma is a cancer which usually starts in the skin either in a mole or in normal-looking skin About half of all melanomas start in normal skin

The number of people who develop melanoma is continuing to rise More than 8900 people in the UK are diagnosed with melanoma each year

Melanoma is more common in women particularly young women In the UK itrsquos the most common cancer in people aged 15ndash34 but like most cancers itrsquos more usual for it to happen in older people as our risk of cancer rises with age Melanoma is rare in children under 14

People with black or brown skin are much less likely to get melanoma as their skin is more naturally protected against it

In women the most common place to develop melanoma is on the legs in men itrsquos on the chest or back

How melanoma develops

Melanoma develops from melanocytes In melanoma the melanocytes start to grow and divide more quickly than usual and start to spread into the surrounding surface layers of skin When they grow out of control they usually look like a dark spot or mole on your skin

Finding and treating melanoma as early as possible is very important If a melanoma is not removed the cells can grow down deeper into the layers of the skin These layers contain tiny blood vessels and lymph channels Lymph channels are tiny tubes which carry lymph fluid and connect to lymph nodes (sometimes called glands) throughout the body This is part of our immune system which helps us to fight against infection

If the melanoma cells go into the blood vessels or lymph channels they can travel to other parts of the body

What is cancer

The organs and tissues of the body are made up of tiny building blocks called cells Cancer is a disease of these cells

Cells in different parts of the body may look and work differently but most reproduce themselves in the same way Cells are constantly becoming old and dying and new cells are produced to replace them Normally cells divide in an orderly and controlled manner If for some reason the process gets out of control the cells carry on dividing developing into a lump which is called a tumour

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Tumours can be either benign or malignant Cancer is the name given to a malignant tumour Doctors can tell if a tumour is benign or malignant by examining a small sample of cells under a microscope This is called a biopsy

In a benign tumour the cells do not spread to other parts of the body and so are not cancerous However if they continue to grow at the original site they may cause a problem by pressing on the surrounding organs

A malignant tumour consists of cancer cells that have the ability to spread beyond the original area If the tumour is left untreated it may spread into and destroy surrounding tissue Sometimes cells break away from the original (primary) cancer They may spread to other organs in the body through the bloodstream or lymphatic system

The lymphatic system is part of the immune system - the bodys natural defence against infection and disease It is a complex system made up of organs such as bone marrow the thymus the spleen and lymph nodes The lymph nodes (or glands) throughout the body are connected by a network of tiny lymphatic ducts

When the cancer cells reach a new area they may go on dividing and form a new tumour This is known as a secondary cancer or metastasis

It is important to realise that cancer is not a single disease with a single type of treatment There are more than 200 different kinds of cancer each with its own name and treatment

Types of cancer

Carcinomas

The majority of cancers about 85 (85 in a 100) are carcinomas They start in the epithelium which is the covering (or lining) of organs and of the body (the skin) The common forms of breast lung prostate and bowel cancer are all carcinomas

Carcinomas are named after the type of epithelial cell that they started in and the part of the body that is affected There are four different types of epithelial cells

squamous cells - that line different parts of the body such as the mouth gullet (oesophagus) and the airways

adeno cells - form the lining of all the glands in the body and can be found in organs such as the stomach ovaries kidneys and prostate

transitional cells - are only found in the lining of the bladder and parts of the urinary system

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basal cells - that are found in one of the layers of the skin

A cancer that starts in squamous cells is called a squamous cell carcinoma A cancer that starts in glandular cells is called an adenocarcinoma Cancers that start in transitional cells are transitional cell carcinomas and those that start in basal cells are basal cell carcinomas

Leukaemias and lymphomas

These occur in the tissues where white blood cells (which fight infection in the body) are formed ie the bone marrow and lymphatic system Leukaemia and lymphoma are quite rare and make up about 65 (65 in 100) of all cancers

Sarcomas

Sarcomas are very rare They are a group of cancers that form in the connective or supportive tissues of the body such as muscle bone and fatty tissue They account for less than 1 (1 in 100) of cancers

Sarcomas are split into two main types

bone sarcomas - that are found in the bones soft tissue sarcomas - that develop in the other supportive tissues of the

body

Others forms of cancer

Brain tumours and other very rare forms of cancer make up the remainder of cancers

The skin

The skin has many purposes it

acts as a barrier to protect the body from injury and keeps out infection keeps in necessary fluids and proteins protects the body from the harmful effects of ultraviolet light helps to control our body temperature

Structure Melanocytes

Structure

The skin is divided into two main layers The layer nearest the surface is known as the epidermis and the layer underneath is known as the dermis

The epidermis contains three types of cells On the surface are flat cells known as squamous cells Under the layer of squamous cells are rounder cells called basal cells In between the basal cells are melanocytes

The dermis contains nerve endings blood vessels and oil and sweat glands Itrsquos held together by a protein called collagen

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Structure of the skin

Melanocytes

Melanocytes are cells which produce a pigment called melanin Melanin is responsible for the natural colour of our skin and protects it from the harmful effects of the sun Melanocytes are found in the lower part of the epidermis

When our skin is exposed to a lot of sun our melanocytes increase the amount of melanin to absorb more ultra violet rays This makes the skin darker and gives it a suntanned appearance A suntan is a sign that the skin has been damaged and is trying to protect itself

People with brown or black skin have the same number of melanocytes but make more melanin This means that they have more natural protection from the sunrsquos ultra violet rays

Moles (sometimes called naevi) are just a group or cluster of melanocytes that lie close together Most people with white skin have about 10ndash50 moles on their skin Some young adults can have as many as 100

Types of melanoma

Here are the four main types of skin (cutaneous) melanoma

Superficial spreading melanoma is the most common type of skin melanoma In women the most common place for it to start is on the legs while in men itrsquos on the chest and the back At first the melanoma cells usually grow slowly spreading out across the surface of the skin

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Nodular melanoma is the second most common type but most thin melanomas arenrsquot nodular melanomas It can grow more quickly than other melanomas and is usually found on the chest back head or neck

Lentigo maligna melanoma is usually found in older people in areas of skin that have had a lot of exposure to the sun over many years (most often the face and neck) It develops from a slow growing precancerous condition called a Hutchisonrsquos freckle which looks like a stain on the skin

Acral melanoma is the rarest type and is usually found on the palms of the hands soles of the feet under nails or toenails Itrsquos more common in people with black or brown skin and isnrsquot thought to be related to sun exposure

Rarely melanoma can start in parts of the body other than the skin

Causes and risks of melanoma

The main risk factor for melanoma is exposure to ultra violet (UV) light through natural sunlight or artificially from sunbeds or lamps UV light damages the DNA (genetic material) in our skin cells and can cause skin cancers like melanoma

Sun exposure is not the cause of all melanomas because some melanomas affect parts of the body that arenrsquot exposed to the sun

Ultraviolet (UV) rays from the sun In the UK the number of people developing melanoma and other skin cancers is steadily rising This may be because people take sunshine holidays abroad more often

Ultraviolet light from sunbeds Sunbeds give off artificial UV rays which damage the DNA increasing the risk of developing melanoma The more you use a sunbed or lamp the greater your risk Getting a sunbed tan before you go on holiday can actually increase your risk of melanoma

Itrsquos important for us all to be aware of the damage that too much exposure to the sun can cause Some sunshine is good for us It helps us make vitamin D which keeps bones and teeth healthy and generally makes us feel better But itrsquos important to be aware of the damage that too much exposure to the sun can cause

If yoursquove had a melanoma (or any skin cancer) or are at increased risk of melanoma itrsquos essential to protect yourself from the sun

Other factors that can increase your risk

Your skin type People with fair skin red or fair hair blue eyes and freckles are more sensitive to the sun Because of their skin type they burn more easily and so are more at risk of getting melanoma Having brown or black skin lowers your risk of getting melanoma but it doesnrsquot mean that you will never get one

Sunburn Episodes of severe sunburn especially during childhood can increase the risk of melanoma in the future

Having lots of moles and unusual moles People who have a lot of moles (especially over 100) have a higher risk of getting melanoma People with moles

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which are bigger than usual with an irregular shape or colour (called atypical) have an increased risk These moles (sometimes called dysplastic naevi) rarely change into melanoma but itrsquos important to keep an eye on them Having lots of moles and atypical moles can run in some families Having a very large (more than 20cm in diameter) dark hairy mole which you were born with also increases your risk of melanoma

If you have any of the above you can be referred to a skin specialist for advice and an assessment of your skin

Family history of melanoma This increases your risk especially if you have two or more close relatives who have had melanoma This may be caused by an inherited faulty gene but this area is still being researched People with a very strong family history of melanoma can be referred by their GP to a family cancer clinic (which may be doing research)

Reduced immunity People with a weakened immune system because they have HIV or people taking drugs that suppress the immune system (after an organ transplant) have an increased risk of melanoma

Symptoms of melanoma

About half of melanomas start with a change in normal looking skin This usually looks like a dark area or an abnormal new mole The other half of melanomas develop from a mole or freckle that you already have

It can be difficult to tell the difference between a melanoma and a normal mole The following checklist (known as the ABCDE list) will give you an idea of what to look out for

Asymmetry ndash Melanomas are likely to be irregular or asymmetrical Ordinary moles are usually symmetrical (both halves look the same)

Border ndash Melanomas are more likely to have an irregular border with jagged edges Moles usually have a well-defined regular border

Colour ndash Melanomas tend to have more than one colour They may have different shades like brown mixed with black red pink white or a bluish tint Moles are usually one shade of brown

Diameter ndash Melanomas are usually more than 7mm in diameter Moles are normally no bigger than the blunt end of a pencil (about 6mm across)

Evolving (changing) ndash Look for changes in the size shape or colour of a mole

See your doctor straight away if you have

any of the ABCDE signs a mole that is changing in size shape or colour tingling or itching in a mole crusting or bleeding in a mole something growing under a nail or a new pigmented line in a nail

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Melanoma can usually be cured if itrsquos found at an early stage

How melanoma is diagnosed

Usually you will begin by seeing your GP who will examine you If your GP thinks you may have a melanoma they should refer you urgently to a doctor with specialist training in diagnosing skin cancer

Seeing a specialist Giving your consent Removing the mole (excision biopsy)

Seeing a specialist

If you have a suspected melanoma you should be seen within a couple of weeks by a skin cancer specialist Your appointment will usually be at a skin clinic or at a pigmented lesion clinic (a special clinic for diagnosing melanomas early) You will see a skin specialist (dermatologist) or a plastic surgeon These doctors are experienced in treating skin cancers

Your specialist will examine your mole and ask you questions about how long yoursquove had it and the changes yoursquove noticed They usually also examine the rest of your skin to see if you have any other unusual moles

Some specialists may look at your moles with a small hand held instrument called a dermatoscope This gives a bigger and clearer picture of the mole but itrsquos not always necessary to have this test Your specialist will be able to tell a lot by just looking at your mole

If they think you have a melanoma your specialist will ask you to have the whole mole removed (excision biopsy) You may also be introduced to a specialist skin cancer nurse who will give you information and support

Giving your consent

Before your mole is removed your doctor will explain the aims of the treatment to you Yoursquoll usually be asked to sign a form saying that you give your permission (consent) for the mole to be removed Your doctors or specialist nurse will explain the procedure and talk to you about any possible complications such as bleeding or infection although these are unusual Theyrsquoll also explain that you will have a small scar as a result of having your mole removed

Removing the mole (excision biopsy)

Once yoursquore lying down comfortably your doctor will inject a local anaesthetic around the area of the mole After this they will cut out the whole mole and a tiny amount of skin around it (2ndash5mm) You wonrsquot feel this because the local anaesthetic numbs the area Your doctor will then close the wound using stitches which will be removed after 5ndash14 days Some people may have stitches which dissolve and donrsquot need to be removed

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The mole is examined under the microscope by a pathologist to see if any melanoma cells are present You usually get the results within a few weeks when you return to the clinic

When itrsquos confirmed that it was a melanoma your specialist may talk to you about having further surgery known as a wide local excision A wide local excision is done to make sure that all the melanoma cells in the area have been removed This is explained in the section on treatment

Staging melanoma

The stage of a cancer is a term used to describe the size of the cancer and whether it has spread Knowing the stage of a cancer helps doctors decide on the best treatment for you The staging system that is used for melanoma is the American Joint Committee on Cancer (AJCC)

AJCC staging system

This uses the TNM system

T stands for tumour This is based on the thickness of the melanoma (using Breslow thickness) and also looks at whether the melanoma is ulcerated

N stands for spread to lymph nodes (sometimes called glands) M is whether the melanoma has spread to other parts of the body (secondary

or metastatic cancer)

Breslow thickness

As well as the AJCC system an important measurement for melanoma is how thick it is This is called the Breslow thickness (named after the doctor who introduced it) Itrsquos the distance in millimetres from the surface of the skin to how far down the deepest melanoma cells are Thin melanomas (less than 1mm) have a very high chance of being cured

Ulceration

A melanoma is said to be ulcerated if the layer of skin covering the melanoma cannot be clearly seen If itrsquos not ulcerated the letter a is added to the stage and if it is ulcerated the letter b is added

Thin melanoma less that 1mm is always stage 1 in the AJCC system It will either be stage 1a or stage 1b depending on whether or not it is ulcerated

Melanoma in situ

Melanoma in situ or melanocytic intraepithelial neoplasia (MIN) is the very earliest stage of melanoma The melanoma cells are just in the very top layer of skin (epidermis) and havenrsquot started to spread into the surrounding skin Itrsquos called a Stage 0 melanoma and itrsquos sometimes described as precancerous Lentigo maligna is a type of melanoma in situ

Melanoma in situ can be cured and there shouldnrsquot be any risk of it coming back after surgery

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Treating thin melanoma (less than 1mm)

The only treatment needed for a thin melanoma is

removing the whole mole wide local excision (to make sure no melanoma cells are left behind)

After your whole mole has been removed (see diagnosis) and the results show that it is a melanoma your specialist may ask you to have a wide local excision If enough clear tissue was taken away when your melanoma was removed you might not need to have a wide local excision

Wide local excision Change in appearance Benefits and disadvantages of treatment

Wide local excision

The surgeon removes a small amount (margin) of normal-looking tissue all around the area where the melanoma was This is to make sure that no melanoma cells have been left behind

You will usually have this done under local anaesthetic in the day surgery unit in the same way as you had your mole removed It may sometimes be done under general anaesthetic

The surgeon usually removes at least 1cm of skin all around the melanoma Your specialist nurse will give you information and advice about looking after the area It will look red and sore at first but this will gradually settle Your stitches will be removed after 5ndash14 days You will be left with a scar which is usually small and will eventually fade

Very occasionally a wider area of skin is removed and the surgeon may need to do a skin graft Skin grafts are layers of skin taken from another part of the body and placed over the area where the melanoma has been removed However you donrsquot usually need to have a skin graft if you have a thin melanoma removed

Change in appearance

If the melanoma was on a visible part of your body (exposed) such as your face or neck and its removal has changed your appearance this may be difficult to come to terms with Some skin clinics have a make-up specialist who will help you find the best way to cover up scars There are also some organisations that provide camouflage make-up to cover up scars

Coping with a change in how you look can be difficult Itrsquos important to get support and many people find it helps to talk things through with someone close or a trained counsellor

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Benefits and disadvantages of treatment

Surgery has a very high chance of curing a thin melanoma The surgery will leave a scar on the skin but this will fade and may not be noticeable depending on where your melanoma was Without surgery melanoma is likely to spread into the deeper layers of the skin and may then spread to other areas of the body

If you have any questions donrsquot be afraid to ask your doctor or the nurses looking after you It often helps to make a list of questions for your doctor and to take a close friend or relative to the discussion with you

Treatment of stage 2 and 3 melanoma

Stage 2 is when the melanoma is more than 2mm thick or more than 1mm thick and ulcerated (the skin is broken) Stage 3 is where melanoma cells are found in one or more lymph nodes

After diagnosis and initial treatment you may have further tests to check if the cancer has spread to the lymph nodes and further treatment to try to reduce the risk of the melanoma coming back

The lymph nodes Further tests Further treatment

The lymph nodes

The lymph nodes are part of the lymphatic system which is part of the bodys natural defence against infection The lymph nodes (sometimes called glands) are situated throughout the body and are connected by very fine lymphatic vessels Fluid drains from the tissues into the lymphatic system

The lymphatic system

Sometimes melanoma cells can travel to the lymph nodes If you have melanoma your doctor may suggest further tests to see if it has spread

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Further tests

Fine needle aspiration (FNA)

Your doctor may suggest this if you have a swollen lymph node The doctor uses a fine needle and syringe to take some cells from the swollen node These are then examined in the laboratory

Sentinel node biopsy

Your surgeon may suggest that during or after your operation you have a sentinel node biopsy to see if the melanoma cells have spread to the lymph nodes The sentinel node is the one closest to the melanoma To identify the sentinel node two substances are injected into the area ndash one is mildly radioactive and the other is coloured blue The surgeon removes the node which has taken up these liquids (the sentinel node) so it can be tested to see whether it contains melanoma cells

The risk of problems following the sentinel node biopsy is very low They include infection or having some fluid collect in the area These can easily be treated

Sentinel node biopsy is still being researched in trials to see how effective it is

If you have a sentinel node biopsy you may not need to have any other lymph nodes removed If melanoma cells are found in the sentinel node your doctor will suggest another operation (lymph node dissection) to remove more of the lymph nodes in the area

Lymph node dissection

This is an operation to remove all the lymph nodes in the area It is sometimes called a block dissection and is done under a general anaesthetic You will have some soreness for a few weeks after the operation but hopefully it should not stop you doing any of your normal activities Your doctor or nurse will give you detailed advice about what you can or canrsquot do Sometimes the removal of lymph nodes may cause a gradual swelling in the limb where the glands were removed This is called lymphoedema

The following tests may be done either before or after you have a lymph node dissection

Blood tests

To check your general health

Chest x-ray

To check your general health and look for any signs of melanoma in the lungs

Liver and abdominal ultrasound scan

This uses sound waves to make up a picture of a particular area of the body Once you are lying comfortably on your back a gel is spread on your abdomen A small device like a microphone is then passed over the area The echoes are converted into a picture by a computer

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CT scan (computerised tomography scan)

A series of x-rays is taken of the chest and abdomen These are fed into a computer to build up a detailed picture of the bodys organs and may show whether the melanoma has spread The scan takes from 10 to 30 minutes You may be given a drink or injection of a dye which allows particular areas to be seen more clearly For a few minutes this may make you feel hot all over If you are allergic to iodine or have asthma you could have a more serious reaction to the injection so it is important to let your doctor know beforehand You will probably be able to go home as soon as the scan is over Your doctor may also want you to have a CT scan of your brain

Further treatment

Treatment is sometimes used after surgery to try to reduce the risk of the melanoma coming back This is called adjuvant treatment At the moment there is no standard adjuvant treatment for stage 2 or 3 melanoma although treatment with a drug called interferon is sometimes suggested

Interferon is a substance produced by the body to fight viral infections such as flu A man-made version is available The aim is that interferon will help stimulate the bodyrsquos own immune system to fight the melanoma Interferon is given as an injection just under the skin (subcutaneously) usually three times a week Interferon can cause side effects similar to flu symptoms (fever chills headache tiredness) Although these can be troublesome they gradually disappear once the treatment is over

Treatment for advanced (stage 4) melanoma

Melanoma can spread to other areas in the body including the lungs liver lymph nodes and the brain It can also affect other areas of skin some distance from where it first started Melanoma which has spread is called advanced or stage 4 melanoma Doctors also use terms like secondary or metastatic cancer which means cancer that has spread from its original site

The treatment you have will depend on where the melanoma has spread to your general health and what treatment you have already had

Further tests used to diagnose stage 4 melanoma Treatment Advantages and disadvantages of treatment New treatments

Further tests used to diagnose stage 4 melanoma

You may have several different tests depending on the symptoms you have These can include

Blood tests

To check your general health

Chest x-ray

To check your general health and look for any signs of melanoma in the lungs

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Liver and abdominal ultrasound scan

This uses sound waves to make up a picture of a particular area of the body Once you are lying comfortably on your back a gel is spread on your abdomen A small device like a microphone is then passed over the area The echoes are converted into a picture by a computer

CT scan (computerised tomography scan)

A series of x-rays is taken of the chest and abdomen These are fed into a computer to build up a detailed picture of the body organs and may show whether the melanoma has spread The scan takes from 10 to 30 minutes You may be given a drink or injection of a dye which allows particular areas to be seen more clearly For a few minutes this may make you feel hot all over If you are allergic to iodine or have asthma it is important to let your doctor know this beforehand as you could have a serious reaction to the injection You will probably be able to go home as soon as the scan is over Your doctor may also want you to have a CT scan of your brain

MRI scan (magnetic resonance imaging scan)

This test is similar to a CT scan but uses magnetism instead of x-rays to build up a detailed picture of areas of your body You will be asked to lie very still on a couch inside a long tube for about 30 minutes It is painless but can be slightly uncomfortable and some people feel a bit claustrophobic during the scan It is also noisy but you will be given earplugs or headphones Some people are given an injection of dye into a vein in the arm but this usually does not cause any discomfort

Treatment

Treatment for advanced melanoma aims to slow down the progress of the cancer It can also help with some of the symptoms You may want to discuss the aims of treatment with your doctors

Surgery

If the melanoma is in the skin the lymph nodes or in a single part of the brain your doctors may suggest an operation to remove it Surgery can also be used to help relieve symptoms of advanced melanoma

Biological therapies

Biological therapies are based on substances naturally produced in the body The main one used in melanoma treatment is interferon Interferon is produced by the body to fight viral infections A man-made version is available The aim is that interferon will help stimulate the bodyrsquos own immune system to fight the cancer Interferon is given as an injection just under the skin (subcutaneously) usually three times a week It can cause side effects similar to flu symptoms (fever chills headache and tiredness) Although these can be troublesome they gradually disappear once the treatment is over Another type of biological therapy is interleukin This is used more often in the USA Interleukin tends to cause more side effects than interferon There is no evidence that either drug is more effective than the other

Chemotherapy

Chemotherapy is the use of anti-cancer drugs to destroy cancer cells A drug called dacarbazine (DTIC) can be used to treat advanced melanoma Sometimes it is used with other chemotherapy drugs Most chemotherapy is given by an infusion (drip) into

22

one of the veins in your arm (intravenously) It is usually given every three or four weeks Another chemotherapy drug temozolomide (Temodalreg) is also being used in research trials for melanoma

Isolated limb perfusion

If the secondary melanoma is confined to just an arm or a leg your doctors may suggest isolated limb perfusion This is a specialised procedure only available at some hospitals which allows chemotherapy to be given to just one limb The side effects are reduced because the chemotherapy does not affect the rest of the body

Radiotherapy

Radiotherapy uses high-energy rays to destroy cancer cells while doing as little harm as possible to normal tissue It may be used if for example cancer has spread to the bones as it can help relieve pain It may also be used to treat melanoma in the skin and brain

Advantages and disadvantages of treatment

Treatment for advanced melanoma can only control the cancer and lead to an improvement in symptoms and quality of life However for some people the treatment will have very little effect on the cancer and they will get the side effects without many of the benefits

If a cure is not possible and the treatment is being given to control the cancer you may want to consider whether you wish to have treatment Making decisions in these circumstances is always difficult and you may need to discuss your situation in more detail with your doctor If you choose not to have treatment you can still be given supportive care (also known as palliative care) with medicines to control any symptoms

New treatments

Cancer vaccines

Vaccines are being researched to see if they are useful to treat melanoma It is hoped that cancer vaccines will help stimulate the bodyrsquos own immune system to destroy the cancer cells

Biochemotherapy

This treatment uses a biological treatment such as interferon in combination with chemotherapy to treat melanoma

Follow-up after treatment for melanoma

After the melanoma has been removed your skin cancer specialist will want to see you again You may only be asked to come back for a couple of visits until your scar has settled down or you may have regular check-ups every few months for a period of time This varies with different hospitals and will depend on the advice given by

23

your skin cancer specialist If you had a melanoma in situ you will usually only be seen once after itrsquos been removed

Although itrsquos very unlikely that your original melanoma will come back you are at more risk of developing another primary melanoma (second primary) Because of this you will be shown how to examine your skin and what to look for Yoursquoll also be given advice on protecting yourself from the sun

At the clinic What to look for

At the clinic

Your doctor or specialist nurse will examine your scar and the surrounding area They will also check the lymph nodes close to the area where the melanoma was removed

If your melanoma was in the

Leg - The lymph nodes behind your knees and in your groin will be checked Chest back or abdomen - The lymph nodes in your groin armpits above the

collar bones and in the neck will be checked Arm - The lymph nodes in the armpit on the affected side above your collar

bones and in the lower neck will be checked Head or neck area - The lymph nodes in the sides of your neck under the

chin above the collar bones behind your ears and at the back of your neck will be checked

Some people may have photographs taken of their skin and some of their moles measured This is just a way of comparing and keeping a check on any changes that may develop

For people whose treatment is over apart from these check-ups our booklet life after cancer gives useful advice on how to keep healthy and adjust to life after treatment

What to look for

Your specialist nurse or doctor will give you advice about what to look for and how to examine yourself Itrsquos important to do this at least once a month because of the risk of getting another primary melanoma and of the small risk of your melanoma coming back The earlier anything like this is picked up the more chance there is of curing it

Yoursquoll be asked to check (by looking and feeling)

your scar and the surrounding area the lymph nodes nearby your skin from head to toe for any new or changing moles (using the ABCDE

guide)

After a while checking your skin will get easier yoursquoll become more familiar with your skin and what your moles normally look like A good time to do this is after a bath or shower Make sure that you have plenty of light Use a full length mirror and a small

24

hand held mirror for areas that are hard to reach You can ask a partner relative or friend to look at your back and parts of your skin that are hard to see

After melanoma

Most people with thin melanoma will be cured and getting back to normal after surgery is usually straightforward The main change is that from now on yoursquoll have to make sure you protect yourself from the sun You may also feel anxious or upset for a while but these feelings usually get better as things get back to normal

Some women have concerns about becoming pregnant taking the contraceptive pill or hormone replacement therapy (HRT) after melanoma Therersquos no evidence however that getting pregnant taking the contraceptive pill or hormone replacement therapy (HRT) increase the risk of melanoma coming back

Skin care in the sun How you might feel

Skin care in the sun

After any treatment for malignant melanoma itrsquos very important to avoid strong sunlight This reduces the chance of developing a second melanoma

Protecting yourself from the sun doesnrsquot mean that you can no longer enjoy sunshine or have holidays in sunny countries but yoursquoll need to take sensible precautions which will in time become part of your normal routine There are a number of things you can do to protect your skin

Never allow your skin to burn Stay out of the sun or strong sunlight during the hottest part of the day ndash

usually between 11am and 3pm Wear clothing made of cotton or natural fibres which have a close weave and

give more protection against the sun

Keep your legs and arms covered by wearing long sleeves and trousers Protect your face and neck with a wide-brimmed hat

Always wear sunglasses in strong sunlight Use a high-factor sunscreen (SPF15 or above) whenever you are exposed to

the sun Follow the instructions on the bottle and re-apply it as recommended especially after swimming Choose one that protects against both UVA and UVB radiation (called broad spectrum)

Donrsquot use sunscreen to stay out in the sun for longer or instead of clothing to protect your skin The best protection is to cover up and to stay out of strong sunlight

Never use a sunbed or sunlamp If itrsquos important for you to look tanned use fake tanning lotions or sprays

25

How you might feel

Although your melanoma is likely to be cured you may feel anxious or upset for a while Talking to family and friends about how you are feeling often helps You can also talk to your doctor or specialist nurse for advice and support

Occasionally some people may need more than advice and support from their health professionals and family and friends Sometimes itrsquos easier to talk to someone whorsquos not directly involved Your specialist or GP can usually refer you to a trained counsellor who can help

Research - clinical trials for melanoma

You may be offered further treatment as part of a clinical trial Treatment may be with either interferon or a cancer vaccine

Vaccines are being used in trials to try to control the growth of melanomas that have already spread There are several different types of vaccine but they are produced in similar ways

Research into new ways of treating melanoma is going on all the time

For stage 2 and 3 melanoma trials are looking into whether adjuvant treatment reduces the chance of the cancer coming back

For advanced melanoma trials are looking at new drugs to see if they are effective at treating melanoma

Clinical trials can take some time There can be many benefits in taking part in a trial You will be helping to improve knowledge about melanoma and the development of new treatments You will also be carefully monitored during and after the study

It is important to bear in mind that some treatments which look promising at first are often later found not to be as good as existing treatments or to have side effects that outweigh any benefits

JASCAP resources for living with cancer

Talking about your cancer Practical advice and guidance for cancer patients to help them communicate with family friends carers and health professionals about emotional and practical issues arising from a diagnosis of cancer and cancer treatment

Talking to children about cancer

Practical advice and guidance to help parents with cancer talk to their children about their cancer

26

Talking to someone with cancer Practical advice and guidance for friends carers and family members to help them talk to their friend or relative with cancer and provide emotional and practical support Note JASCAP has booklets on each of the above subjects

27

Questions you might like to ask your doctor or surgeon

You can fill this in before you see the doctor or surgeon and then use it to remind yourself of the questions you want to ask and the answers you receive

1 _______________________________________

Answer _______________________________________

_____________________________________________

2 _______________________________________

Answer _______________________________________

_____________________________________________

3 _______________________________________

Answer _______________________________________

_____________________________________________

4 _______________________________________

Answer _______________________________________

_____________________________________________

5 _______________________________________

Answer _______________________________________

_____________________________________________

28

JASCAP We need your help

We hope that you found this booklet useful To help other patients and their families we need and intend to extend our Patient Information Services in many ways

Our Trust depends on voluntary donations Please send your donation by Cheque or DD payable in Mumbai in favour of ldquoJASCAPrdquo

Note for Reader This JASCAP booklet is not designed to provide medical advice or professional services and is intended to be for educational use only The information provided through JASCAP is not a substitute for professional care and should not be used for diagnosing or treating a health problem or a disease If you have or suspect you may have a health problem you should consult your doctor

29

JASCAP JEET ASSOCIATION FOR SUPPORT TO CANCER PATIENTS

CO ABHAY BHAGAT amp CO OFFICE NO4 ldquoSHILPArdquo

7TH ROAD PRABHAT COLONY

SANTACRUZ (East)

MUMBAI - 400 055

PHONE 91-22-2617 7543 amp 91-22-2616 0007

FAX 91-22-2618 6162

e-mails pkrjascapgmailcom abhayabhaybhagatcom

AHMEDABAD MR DKGOSWAMY

1002 LABH SHUKAN TOWER

NEAR JUDGESrsquo BUNGALOWS

AHMEDABAD - 380 015

PHONE 91-79-6522 4287 Mob 93270 10529

e-mail dkgoswamysifycom

BANGALORE MS SUPRIYA GOPI

455 I CROSS

HAL III STAGE

BANGALORE ndash 560 075

PHONE 91-80-2528 0309

e-mail supriyakgopiyahoocoin

HYDERABAD MS SUCHITA DINAKER amp DR M DINAKER MD

FLAT NO G4 1ST FLOOR ldquoSTERLING ELEGANZArdquo

STREET NO5 NEHRUNAGAR

SECUNDERABAD ndash 500 026

PHONE 91-40-2780 7295

e-mail suchitadinakeryahoocoin